treatment of breast disease Flashcards
incidence of breast cancer
1/8 women account for 1/4 of malignancies in women 55, 000 new cases p/a UK >490 new cases p/a in Grampian >9000 diagnosed each year are <50y/o >11 400 deaths p/a ~300 new cases p/a in men
risk factors for breast cancer
age - increased incidence previous breast cancer genetic: BRCA1, BRCA2 (5%) early menarche and late menopause late/no pregnancy HRT alcohol (>14 units/wk) weight post RT treatment for Hodgkin's disease
why is weight a risk factor for breast cancer
increased fat
increased storage of oestrogen
presentation of breast cancer - where would it be picked up
asymptomatic - breast screening (50-70y/o)
symptomatic - outpatient clinic
symptomatic presentation of breast cancer
lump mastalgia - persistent unilateral pain nipple discharge - blood stained nipple changes - Paget's disease, retraction change in size/shape of the breast lymphoedema - swelling of arm dimpling of breast skin
new patient clinic - investigations
TRIPLE ASSESSMENT
- clinical - hx and examination
- radiological - bilateral mammograms/US
- cyto-pathological - FNA (cells only, cytology), core biopsy (tissue, histopathology)
triple assessment: clinical assessment
HX: PC previous breast problems FHx hormonal status drug Hx
examination:
BOTH breasts - start with normal breast
axillae
SCF - supraclavicular fossae
common signs and symptoms of breast cancer
most common - lump/thickening in breast, often painless
discharge or bleeding
change in size/contours of breast
inversion - is this new or has it always been inverted
change in colour/appearance of areola
redness or pitting of skin over breast (peau d’orange) - sign of inflammatory breast cancer
triple assessment: breast imaging
mammography, US, MRI
mammography is the most sensitive in older women
MRI - only for lobular cancer, dense breasts or other benign disease present
sensitivity is reduced in young women due to presence of increased glandular tissue (<35y/o)
triple assessment: cytology and histology
FNA - cytology
core biopsy - histopathology, invasive VS in-situ ER/PR/HER2 receptor status
how sensitive are the investigations
clinical examination 88%
mammography 93%
US 88%
FNA cytology 94% - diagnostic
importance of HER2 receptor status
prognostic factor
pathological types of breast cancer
invasive:
80% ductal carcinoma
10% lobular carcinoma
10% others - mucinous, tubular, papillary, medullary, sarcoma, lymphoma
non-invasive:
DCIS - ductal carcinoma in situ, 17% screening detected
LCIS - lobular carcinoma in situ
management of cancer
- diagnosis
- staging
- definitive treatment
treatment of breast cancer - MDT approach
breast surgeon radiologist cytologist pathologist clinical oncologist - systemic and radiotherapy medical oncologist - systemic therapy nurse counsellor psychologist reconstructive surgeon patient and partner palliative care
staging of breast cancer - how do we do it
FBC, U+Es, LFTs, Ca2+/PO2-
CXR
others as clinically indicated
no reliable tumour markers
breast cancer TNM staging - T
TX - 1y tumour cannot be assessed T0 - 1y tumour not palpable T1 - clinically palpable tumour <2cm T2 - 2-5cm T3 - tumour >5cm T4a - invading skin T4b - invading chest wall T4c - skin and chest wall invasion T4d - inflammatory breast cancer (worst type)
breast cancer TNM staging - N
N0 - no regional LNs palpable
N1 - regional LNs palpable, mobile
N2 - regional LNs palpable, fixed
breast cancer TNM staging - M
MX - distant mets cannot be assessed
M0 - no distant mets
M1 - distant mets
management/treatment options
neoadjuvant (before surgery) VS adjuvant (after surgery)
surgery
+/- RT
+/- chemotherapy
+/- hormonal therapy
what are the 2 main types of surgical procedure
breast conservation surgery
mastectomy
randomized controlled trials - breast conservation + RT = mastectomy for overall survival in tumours <4cm
patients suitable for breast conservation surgery
previously - tumour size <4cm, single tumours
BREAST/TUMOUR SIZE RATIO
suitable for RT
patient’s wish! - most important
types of therapeutic mammoplasties
omega shape - horizontal line across the breast, runs above the nipple
wise pattern - round the nipple then straight down
types of mastectomies
simple
skin sparing with immediate implant reconstruction
surgery to the axilla
prognostic info/staging
regional control of disease/eradication in the axilla
sentinal LN biopsy
first node to recieve lymphatic drainage
first node tumour spreads to
if -ve, rest of nodes in lymphatic basin are -ve
only performed when pre-op axillary US normal/benign
treatment of the axilla
if SLN is -ve = no further treatment required
if SLN contains tumour = remove them all surgically (clearance = ANC) OR give RT to all the axillary nodes
complications of axillary treatment
lymphoedema - 10-17%
sensory disturbance - intercostobrachial n.
decrease ROM of shoulder joint
nerve damage (long thoracic, thoracodorsal, brachial plexus)
vascular damage
radiation induced sarcoma
factors associated with increased risk of disease recurrence
nottingham prognostic index:
- lymph node involvement
- tumour grade
- tumour size
steroid receptor status (ER/PR -ve)
HER2 +ve
LVI - lymphovascular invasion
prevention/adjuvant treatment
local RT
systemic: hormonal, chemotherapy, targeted therapies
radiotherapy - who gets it and how long for
all patients after wide local excision as adjuvant treatment
over 3wks
boosts reduce local recurrence (for younger patients)
after mastectomy if there is local involvement/significant LN involvement
complications of RT - immediate - longterm
skin reaction - skin telangiectasis
radiation pneumonitis
cutaneous radionecrosis/osteonecrosis
angiosarcoma
hormonal therapy - who gets it, how does it work, what are the types
only for oestrogen +ve cancers
blocks stimulation of cell growth by oestrogen
tamoxigen, aromatase inhibitors
tamoxifen - dose, how does it work, effectiveness, who can have it, side effects
20mg once daily for 5-10yrs
blocks directly on ER receptor
effective in all age groups (can be given to premenopausal women), more effective given after chemotherapy
thromboembolic events - CI if prev PE/DVT
low risk of endometrial cancer
aromatase inhibitors - dose, how does it work, effectiveness, who can have it, side effects
(arimidex 1mg and letrozole 2.5mg) once daily for 5yrs inhibiting ER synthesis should only be used in postmenopausal women improve disease free survival
osteoporosis
chemotherapy - where is the greatest benefit
<50y/o
pts w/ increasing adverse prognostic factor - grade 3, LN +ve, ER -ve, HER2 +ve
traditional chemotherapy
1st gen - CMF combinations, not used anymore
2nd gen - anthracycline combinations (doxorubicin or epirubicin)
3rd gen - taxane based combinations e.g. Docetaxel, more potent
oncotype Dx
21 gene assay to determine whether chemotherapy is likely to be of benefit
generates recurrence score:
<25 - don’t benefit from chemotherapy
>25 - would benefit
- info is only from ER+/HER2 -, LN- pts
HER2 positivity and anti-HER2 therapy - different types
trastuzumab (Herceptin)
pertuzumab - only in neoadjuvant chemotherapy setting
HER2 positivity and anti-HER2 therapy - what is it, who gets it, benefits
monoclonal antibody against HER2 receptor
pts w/ over-expression of HER2 and chemotherapy
50% decrease risk of recurrence, 33% increase in survival at 3yrs
follow up for breast cancer
many different protocols - poor evidence base
clinical examination for 1-5yrs
mammogram of breasts at yrly intervals for 3-10yrs
patient is the best person to keep an eye on it
open access to service
metastatic spread of breast cancer
local - chestwall, skin, nipple
distant - contralateral breast, bone, lung, liver, brain, bone marrow
